In 2016, the Critical Care Societies Collaborative (CCSC) published a call to action to address burnout in the intensive care unit (ICU).1 Not all hospitals answered the call.

“Some critical care clinicians report that organizational and individual measures are being implemented,” says Ruth Kleinpell, PhD, RN, FAAN, FAANP, FCCM, assistant dean for clinical scholarship and professor at Vanderbilt University School of Nursing.

Others report the opposite, that nothing much is happening at their institutions. Researchers from the CCSC surveyed 688 critical care clinicians on how their organizations were addressing burnout.2 When reporting the perceived importance placed on mitigating burnout, only 10.9% of respondents reported it as “highly important.”

“Providing resources to support ICU clinicians, including access to ethics consultations and integrating ethical discussions on patient care rounds, is important,” Kleinpell says.

Hospitals are facing an immediate ethical challenge to restore the mental health and wellness of clinical staff. “This varies greatly from hospital to hospital. Some have done a lot of work around this area, while others haven’t focused on it as much,” says Mike Hastings, MSN, RN, CEN, president of the Emergency Nurses Association (ENA). Above all, says Hastings, “hospitals need to have clear lines of communication with their front lines about the situation.”

(Editor’s Note: ENA offers a podcast on burnout and self-care, as well as a peer-to-peer program to facilitate discussions about what emergency department nurses have faced during the COVID-19 pandemic. Both are available here.)

Frontline staff deserve to know why policies are changing and how it will affect them. Visitor restrictions are a good example, according to Hastings. Nurses wanted to know how those would be enforced, and how special circumstances would be handled.

“There are many scenarios that our frontline staff can face,” he explains. “They just want to know how to best respond when they are faced with the situation.”

This became clear during the recent shortages of personal protective equipment (PPE). Nurses lacked specifics on what was going to be provided, and struggled to gauge their personal risk — and their patients’ risk. “The fear of the unknown is far worse than the known,” Hastings says. Select hospitals set up town hall events so staff could ask senior leaders questions. For nurses, “this appears to have helped staff with some of their fears,” Hastings reports. For hospital leaders, “it is OK not to know everything. It is OK to say, ‘I do not know. However, I am also concerned,’” he adds.

Another group of researchers conducted in-person interviews with 20 nurses and physicians from the pediatric ICU and intermediate care unit at a children’s hospital in 2017 and 2018.3 The focus was on self-care.

“Research shows that some people experience burnout, but others do not, which ignited my interest in knowing the factors influencing clinicians’ well-being,” says Holly Wei, PhD, RN, CPN, NEA-BC, one of the study’s authors and an associate professor at East Carolina University College of Nursing.

The study revealed resilient clinicians practice six specific self-care techniques, whether intentionally or unknowingly: finding meaning in work, connecting with an energy source, nurturing interpersonal connections, developing an attitude of positivity, prioritizing ‘emotional hygiene,’ and recognizing their own unique abilities and contributions. “Promoting clinicians’ well-being has important ethical implications. Their well-being is the underpinning of patient care quality,” Wei says.

Other research revealed healthcare workers responding to the spread of COVID-19 reported high rates of depression, anxiety, insomnia, and distress.4,5 “This has added more stress to a group of professionals who are already faced with increased psychological distress,” Wei observes.

The findings suggest that while organizations and leaders play a significant role in reducing burnout, clinicians also need their own self-care techniques. “When clinicians care for themselves, their wellness is connected to the [wellness] of many others,” Wei says.

Hospital responses aside, individual healthcare providers are ethically obligated to practice self-care, says April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, chief nursing officer for advanced practice nursing at Vanderbilt University Medical Center. This became apparent due to PPE shortages. The health system’s nurse practitioners (NPs) took the attitude that they had to find a way to heed public health guidance, regardless of what their employer provided.

“NPs are very resourceful. We do what is necessary to protect others. If it means being creative and making a cloth mask, we will do it,” Kapu says. “We are not going to sit around and wait for someone to give us one.”

Kapu says the same mindset is necessary when it comes to preventing burnout. “It is incumbent upon the facility to follow labor guidelines and provide an environment to stay healthy. But it’s also incumbent upon the NP to assure self-care,” she says.

This includes maintaining adequate hydration, selecting healthy foods, exercising, and resting between shifts. As a nurse leader, Kapu provides resources and support for staff, such as online chaplain services, counseling, mindfulness coaching, links to discounts on child care and elder care, and relaxation exercises. “But in the end, it is the NPs’ choice on whether to pursue a path of self-care, or push the limit and exhaust themselves,” Kapu says.

REFERENCES

  1. Moss M, Good VS, Gozal D, et al. An official Critical Care Societies Collaborative statement: Burnout syndrome in critical care health care professionals: A call for action. Am J Crit Care 2016;25:368-376.
  2. Kleinpell R, Moss M, Good VS, et al. The critical nature of addressing burnout prevention: Results from the Critical Care Societies Collaborative’s national summit and survey on prevention and management of burnout in the ICU. Crit Care Med 2020;48:249-253.
  3. Wei H, Kifner H, Dawes ME, et al. Self-care strategies to combat burnout among pediatric critical care nurses and physicians. Crit Care Nurse 2020;40:44-53.
  4. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
  5. Zhang Y, Wei L, Li H, et al. The psychological change process of frontline nurses caring for patients with COVID-19 during its outbreak. Issues Ment Health Nurs 2020;1-6. doi: 10.1080/01612840.2020.1752865.